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1.
Urol Clin North Am ; 49(4): 583-592, 2022 Nov.
Article in English | MEDLINE | ID: mdl-36309415

ABSTRACT

Andropause is a condition surrounded by controversies, whether it be through its diagnosis or management. As we learn more about the pathophysiology of hypogonadism, our perspectives on the risks and benefits of testosterone therapy have shifted. We attempt to discuss the most modern and relevant points of controversy currently affecting the field. Throughout this review, we discuss the art of diagnosing hypogonadism as well as the association or lack thereof between testosterone replacement therapy and cardiovascular disease, prostate cancer, thrombosis, antiaging effects, exogenous steroid abuse, and diabetes mellitus.


Subject(s)
Andropause , Hypogonadism , Prostatic Neoplasms , Male , Humans , Andropause/physiology , Hypogonadism/diagnosis , Hypogonadism/drug therapy , Hormone Replacement Therapy , Testosterone/therapeutic use , Prostatic Neoplasms/diagnosis , Prostatic Neoplasms/drug therapy
2.
Cells ; 10(11)2021 11 19.
Article in English | MEDLINE | ID: mdl-34831456

ABSTRACT

Fecal microbiota transplantation (FMT) is highly effective in recurrent Clostridioides difficile infection (CDI); increasing evidence supports FMT in severe or fulminant Clostridioides difficile infection (SFCDI). However, the multifactorial mechanisms that underpin the efficacy of FMT are not fully understood. Systems biology approaches using high-throughput technologies may help with mechanistic dissection of host-microbial interactions. Here, we have undertaken a deep phenomics study on four adults receiving sequential FMT for SFCDI, in which we performed a longitudinal, integrative analysis of multiple host factors and intestinal microbiome changes. Stool samples were profiled for changes in gut microbiota and metabolites and blood samples for alterations in targeted epigenomic, metabonomic, glycomic, immune proteomic, immunophenotyping, immune functional assays, and T-cell receptor (TCR) repertoires, respectively. We characterised temporal trajectories in gut microbial and host immunometabolic data sets in three responders and one non-responder to sequential FMT. A total of 562 features were used for analysis, of which 78 features were identified, which differed between the responders and the non-responder. The observed dynamic phenotypic changes may potentially suggest immunosenescent signals in the non-responder and may help to underpin the mechanisms accompanying successful FMT, although our study is limited by a small sample size and significant heterogeneity in patient baseline characteristics. Our multi-omics integrative longitudinal analytical approach extends the knowledge regarding mechanisms of efficacy of FMT and highlights preliminary novel signatures, which should be validated in larger studies.


Subject(s)
Clostridium Infections/therapy , Fecal Microbiota Transplantation , Aged , Aged, 80 and over , Animals , Antibodies, Neutralizing/metabolism , Bacterial Toxins/immunology , Chlorocebus aethiops , Clostridium Infections/immunology , Clostridium Infections/microbiology , Cluster Analysis , Feces/microbiology , Female , Gastrointestinal Microbiome , Genomics , Humans , Immunosenescence , Male , Middle Aged , Phylogeny , Receptors, Antigen, T-Cell/metabolism , Time Factors , Treatment Outcome , Vero Cells
3.
Urology ; 157: 155-160, 2021 11.
Article in English | MEDLINE | ID: mdl-34411598

ABSTRACT

OBJECTIVE: To identify the incidence of venous thromboembolism (VTE) risk factors, postoperative VTE, and to assess the morbidity of perioperative pharmacologic VTE prophylaxis in men undergoing inflatable penile prosthesis (IPP) surgery. METHODS: We retrospectively reviewed 215 patients undergoing IPP surgery between July 2017 and June 2019. Univariate and multivariate statistical analyzes were performed to assess pre-operative Caprini risk score and compare post-operative day 0 scrotal drain output, scrotal hematoma formation, and VTE in men who received subcutaneous heparin (SqH) vs those who did not receive SqH. RESULTS: Of 215 IPP patients, 84% were classified as high or highest risk for VTE utilizing the Caprini risk score. A total of 119 (55%) received perioperative SqH with or without additional anti-thrombotics. Post-operative day 0 scrotal drain output was higher in those who received SqH compared to those who did not receive SqH, 99.9 mL vs 75.6 mL, respectively (P = .001). Minor scrotal hematomas occurred in similar rates in patients who received perioperative SqH vs those who did not, 3.8% vs 6.3%, respectively (P = .38). Similar results were found on subgroup analysis when eliminating patients who received SqH concurrently with other anti-thrombotics. The overall rate of postoperative VTE was 0.9%. No post-operative infections occurred. CONCLUSION: Patients undergoing IPP surgery are at elevated risk for VTE. To our knowledge, this is the first study showing SqH use in the perioperative IPP surgery setting is safe when used in conjunction with a scrotal drain. Preoperative VTE risk stratification may be performed and can be used to guide clinical decision making regarding pharmacologic prophylaxis.


Subject(s)
Anticoagulants/therapeutic use , Heparin/therapeutic use , Penile Prosthesis , Prosthesis Implantation/adverse effects , Venous Thromboembolism/etiology , Venous Thromboembolism/prevention & control , Anticoagulants/administration & dosage , Drainage , Hematoma/etiology , Heparin/administration & dosage , Humans , Injections, Subcutaneous , Male , Middle Aged , Postoperative Complications/etiology , Postoperative Complications/prevention & control , Postoperative Period , Retrospective Studies , Risk Assessment , Risk Factors , Scrotum
4.
Colorectal Dis ; 23(3): 718-723, 2021 Mar.
Article in English | MEDLINE | ID: mdl-33064915

ABSTRACT

AIM: Up to 10% of patients who undergo nonurological abdominopelvic operations suffer a ureteral injury. While preoperative ureteral stenting to facilitate identification of the ureter is common, it does not reduce the incidence of intraoperative ureteral injury and is not without risk. As we continue to broaden the application of minimally invasive surgical techniques, a new form of ureteral identification and avoidance that does not rely on tactile feedback is needed. We report our initial experience with intraureteral indocyanine green (ICG) for ureteral identification and avoidance during complex robotic-assisted colorectal surgery. METHOD: Patients undergoing adjunctive ureteral identification during robotic-assisted colorectal surgery were prospectively identified. Each patient underwent intraureteral ICG administration using rigid cystoscopy (22 Fr). A 5-Fr open-ended ureteral catheter was inserted up to 20 cm and used to inject 5 ml of 2.5 mg/ml ICG as the catheter was withdrawn to the ureteral orifice. Intraureteral ICG was then detected using near-infrared laser fluorescence technology (Firefly®). RESULTS: Successful ICG-enhanced ureteral identification and avoidance was performed in 15 of 16 (94%) patients undergoing robotic-assisted colorectal surgery. The median ICG instillation time was 11.5 min (range 4-21 min) and the median operative time with ICG visualization was 489 min (8 h 9 min) [range 268-738 min (4 h 28 min-12 h 18 min)]. No patient experienced intraoperative ureteral injury and there were no adverse sequelae or complications associated with intraureteral ICG administration. CONCLUSION: Intraureteral ICG is a safe and effective method of intraoperative ureteral identification and avoidance during complex robotic-assisted colorectal surgery. Precise and prolonged ureteral visualization was achieved, allowing for long operative times compatible with complex robotic-assisted operations.


Subject(s)
Colorectal Surgery , Robotic Surgical Procedures , Ureter , Coloring Agents , Humans , Indocyanine Green , Ureter/surgery
5.
Int J Urol ; 27(7): 618-622, 2020 Jul.
Article in English | MEDLINE | ID: mdl-32424856

ABSTRACT

OBJECTIVES: To evaluate the timing and distribution of first renal cell carcinoma metastasis after nephrectomy stratified by nodal status. METHODS: We evaluated patients treated with nephrectomy for sporadic, unilateral renal cell carcinoma between 1970 and 2011 who subsequently developed distant metastasis to three or fewer sites. Site-specific metastases-free 2-year survival rates were estimated using the Kaplan-Meier method. Associations of nodal status with time to metastasis were evaluated using multivariable Cox regression models. RESULTS: A total of 1049 patients met the inclusion criteria (135 pN1, 914 pN0/x patients). The median time to identification of first distant metastasis for pN1 patients was 0.4 years (interquartile range 0.2-1.1 years) versus 2.2 years (interquartile range 0.6-6.0 years) in pN0/x patients. The most common site of metastasis was to the lung, but this occurred earlier in pN1 patients (median 0.3 years vs 2.0 years). pN1 was associated with significantly lower site-specific 2-year metastases-free survival when compared with pN0/x for lung (37% vs 70%, P < 0.001), bone (63% vs 87%, P < 0.001), non-regional lymph nodes (60% vs 96%, P < 0.001) and liver metastases (79% vs 91%, P < 0.001). On multivariable analysis, pN1 status remained significantly associated with lung, bone, and non-regional lymph node (all P < 0.001) metastases, but it was no longer associated with liver metastases (P = 0.3). CONCLUSIONS: pN1 nodal status in M0 patients treated with nephrectomy for renal cell carcinoma is associated with more frequent early metastasis to sites conferring poor prognosis when compared with pN0/x. Our findings highlight the importance of rigorous, early surveillance though the multimodal use of a comprehensive history, physical, laboratory and radiological studies, as outlined in societal guidelines.


Subject(s)
Carcinoma, Renal Cell , Kidney Neoplasms , Carcinoma, Renal Cell/surgery , Humans , Kidney Neoplasms/surgery , Lymph Node Excision , Lymph Nodes/surgery , Lymphatic Metastasis , Neoplasm Recurrence, Local/epidemiology , Nephrectomy , Prognosis , Retrospective Studies
6.
J Endourol ; 34(7): 778-781, 2020 07.
Article in English | MEDLINE | ID: mdl-32408768

ABSTRACT

Introduction: Rezum water vapor thermal ablation is a new minimally invasive technique used to treat benign prostatic hyperplasia. Major advantages include minimal anesthesia and recovery time, low rate of sexual side effects, and durable clinical improvement. However, data are lacking regarding use of Rezum in prostate glands >80 cc. Here we seek to examine the clinical outcomes of men with large prostate glands following Rezum. Patients and Methods: We retrospectively reviewed patients who underwent Rezum therapy at our institution since July 2017. Three-month postoperative outcomes were analyzed, including American Urological Association symptom score (AUASS), peak flow, and postvoid residual (PVR). Complications, including hematuria and urinary tract infections, were also assessed. All statistical analyses were conducted using RStudio 1.2.1335. Results: One hundred eighty-two patients undergoing Rezum were identified, of whom 25.8% had prostate volume >80 cc. Mean gland volume in this group was 119 cc and 55.3% were catheter dependent. Following Rezum, statistically significant improvement was seen in AUASS from 22 to 13.4 (p = 0.04) and PVR from 305 to 149 cc (0.05). Statistically significant improvement was seen in peak flow rate from 7.7 to 12.7 mL/second (p = 0.002). In a subset of catheter-dependent patients, the postoperative catheter-free rate was 83% for men with glands >80 cc, which was comparable with 88% in the smaller gland group. Postoperative complication rate was not significantly different between large or small glands. Conclusions: In our experience, Rezum is efficacious in patients with glands >80 cc. Patients experience symptomatic and objective improvement in voiding parameters that is comparable with patients with glands smaller than 80 cc. Among catheter-dependent patients with glands >80 cc, over 80% are catheter free after Rezum. Our experience supports the consideration of Rezum in patients with prostate glands >80 cc; further studies are warranted to confirm long-term outcomes.


Subject(s)
Hyperthermia, Induced , Prostatic Hyperplasia , Humans , Male , Prostatic Hyperplasia/surgery , Retrospective Studies , Treatment Outcome
7.
J Sex Med ; 17(6): 1168-1174, 2020 06.
Article in English | MEDLINE | ID: mdl-32198103

ABSTRACT

BACKGROUND: Adjuvant maneuvers are often necessary to correct residual curvature during inflatable penile prosthesis (IPP) placement in patients with Peyronie's disease (PD). AIM: We present our multicenter experience using collagen fleece as graft material for plaque incision and grafting (PIG) during IPP placement in patients with moderate to severe PD. METHODS: We retrospectively reviewed 51 patients with IPP from 3 sites who underwent PIG with Tachosil (Baxter, IL) collagen fleece. Coloplast (Minneapolis, MN) IPP devices were used. Factors associated with residual curvature, revision, and patient satisfaction were performed using chi-squared analysis. OUTCOMES: We evaluated postoperative outcomes including factors associated with residual curvature, revision, and patient satisfaction. RESULTS: The mean compound curvature was 69.6°. The mean follow-up was 10.6 (range 1-38) months. All patients reported erections sufficient for penetrative intercourse at the last follow-up. Residual curvature <15° was noted in 6 of 51 (12%) patients. 3 patients required device revision. 2 patients experienced temporary glanular paresthesia, and no patients experienced device infection. CLINICAL IMPLICATIONS: In our multicenter study, patients experienced substantial curve correction with minimal complications, and in the few patients who had persistent mild curvature, severe preoperative curvature (>60°) was found to be the only risk factor. STRENGTHS & LIMITATIONS: Our study represents the largest series of patients coming from multiple centers undergoing surgical correction of PD with IPP and collagen fleece grafting. Limitations of this study include the retrospective study design, lack of a comparison group, and modest follow-up. CONCLUSION: PIG using collagen fleece is a safe and effective means of correcting residual curvature after IPP placement in patients with moderate to severe PD. Hatzichristodoulou G, Yang DY, Ring JD, et al. Multicenter Experience Using Collagen Fleece for Plaque Incision With Grafting to Correct Residual Curvature at the Time of Inflatable Penile Prosthesis Placement in Patients With Peyronie's Disease. J Sex Med 2020;17:1168-1174.


Subject(s)
Penile Implantation , Penile Induration , Penile Prosthesis , Collagen , Humans , Male , Penile Implantation/adverse effects , Penile Induration/surgery , Penis/surgery , Retrospective Studies
8.
Transl Androl Urol ; 9(1): 142-150, 2020 Feb.
Article in English | MEDLINE | ID: mdl-32055478

ABSTRACT

BACKGROUND: Up to one in ten patients undergoing cystectomy with urinary diversion develop a ureteroenteric stricture (UES). Despite unrecognized ureteral obstruction contributing to infection, nephrolithiasis, and/or progression of kidney disease, the long-term natural history and risk factors associated with UES remains understudied. Herein, we report our single institutional experience with the long-term incidence, clinical presentation, and risk factors associated with UES formation following urinary diversion. METHODS: We reviewed 2,285 patients who underwent RC with urinary diversion between 1980-2008. UES was defined as radiographic evidence of ureteral obstruction at the level of the ureteroenteric anastomosis. The diagnosis of benign UES was confirmed by pathology. UES-free survival was estimated using the Kaplan-Meier method. The association between clinicopathologic features and the development of a UES were assessed using multivariable models. RESULTS: A total of 192 (8%) patients developed a benign UES, at a median of 7 months (IQR 4-24) following RC, with 5% occurring after 10 years. Seventy seven percent of patients exhibited signs and/or symptoms of ureteral obstruction. Patients who developed a UES had a greater body mass index (BMI) (28 vs. 27), operative time (330 vs. 301 minutes) and were more likely to experience a <30-day Clavien ≥3 complication (all P<0.05). Receipt of abdominal radiation and smoking history were not significantly associated with UES stricture risk. On multivariable analysis, only greater BMI (per 1-unit increase) (OR 1.06, 95% CI: 1.02-1.09; P=0.0009) and <30-day Clavien ≥3 complication (OR 2.85, 95% CI: 1.90-4.28; P<0.0001) were associated with the development of a UES. Development of UES was associated with renal function deterioration. CONCLUSIONS: UES was identified in 8% of patients following RC with urinary diversion, with the majority presenting with symptoms. While the majority of these occur in the first 2 years after surgery, a patients' risk for the development of this complication persists beyond 10 years. Due to the adverse sequelae of UES, long-term functional and imaging surveillance following urinary diversion is warranted, and early reconstruction should be considered.

9.
Urol Oncol ; 37(12): 886-892, 2019 12.
Article in English | MEDLINE | ID: mdl-31427158

ABSTRACT

OBJECTIVE: To characterize the frequency and risk factors of peritoneal carcinomatosis (PC) in patients undergoing open radical cystectomy (RC). METHODS: We identified 3,285 patients with urothelial carcinoma treated with RC for curative intent between 1980 and 2016. At last follow-up, 72.1% (2,370/3,285) of patients had died, with a median follow-up of 8.6 years (Interquartile Range, (IQR) 3.7, 14.1). PC was defined as any recurrence involving the omentum, small bowel, and mesentery. Overall-specific survival (OSS) and cancer-specific survival (CSS) was evaluated using Kaplan-Meier methodology and log-rank test. Risk factors for mortality and recurrence were performed using Cox proportional hazards regression models. RESULTS: One hundred and twenty nine (3.9%) patients were diagnosed with PC, while a total of 1,148 (34.9%) patients experienced recurrence at other sites. Median time to PC vs. other-site recurrence was 1.3 (IQR 1.3, 2.3) and 0.9 (IQR 0.5, 2.1) years, respectively (P= 0.04). Only increasing pathologic stage on multivariable analysis was associated with developing PC (pT1 HR 2.51, 95CI 1.14-5.55, P= 0.02; pT2 OR 2.82, 95CI 1.47-5.43, P= 0.002; pT3+ 2.40, 95CI 1.31-4.42, P= 0.005) over other recurrence patterns. Nodal status and tumor margin status were not associated. Patients with PC experienced worse OSS and CSS than other types of recurrence (P< 0.001). CONCLUSION: PC was identified in almost 4% of patients undergoing open RC. PC is a rare occurrence after RC and primarily impacts patients with locally advanced disease.


Subject(s)
Carcinoma, Transitional Cell/epidemiology , Cystectomy , Peritoneal Neoplasms/epidemiology , Urinary Bladder Neoplasms/surgery , Aged , Carcinoma, Transitional Cell/secondary , Carcinoma, Transitional Cell/surgery , Female , Follow-Up Studies , Humans , Incidence , Kaplan-Meier Estimate , Male , Middle Aged , Neoplasm Staging , Peritoneal Neoplasms/secondary , Risk Factors , Treatment Outcome , Urinary Bladder/pathology , Urinary Bladder/surgery , Urinary Bladder Neoplasms/mortality , Urinary Bladder Neoplasms/pathology
10.
Curr Urol Rep ; 20(2): 10, 2019 Jan 30.
Article in English | MEDLINE | ID: mdl-30701330

ABSTRACT

PURPOSE OF REVIEW: This review summarizes the latest reports in inflatable penile prosthesis (IPP) complication management. RECENT FINDINGS: IPP complications are rare, and reports are limited to retrospective studies. However, recent multi-institutional studies and use of national databases have provided further insight into risk factors for complications. Guidance on complication management is largely limited to techniques recommended by experts within the field. American Urological Association guidelines place IPP implantation as a first line erectile dysfunction treatment. However, the majority of cases are performed by low-volume (≤ 4 cases/year) surgeons. Herein, we summarize the IPP literature and our personal experience to provide guidance on managing IPP complications.


Subject(s)
Erectile Dysfunction/surgery , Penile Implantation/adverse effects , Penile Prosthesis/adverse effects , Penis/injuries , Dilatation/adverse effects , Dilatation/methods , Humans , Male , Necrosis , Penile Implantation/methods , Penis/blood supply , Penis/pathology , Penis/surgery , Postoperative Complications/diagnosis , Postoperative Complications/therapy , Risk Factors , Urethra/injuries , Urethra/surgery
11.
Transl Androl Urol ; 7(6): 935-940, 2018 Dec.
Article in English | MEDLINE | ID: mdl-30505731

ABSTRACT

BACKGROUND: Limited data are available on how partners of men with Peyronie's disease (PD) are affected by the disease. We sought to characterize PD patients whose curvatures result in pain for their partners during penetrative intercourse. METHODS: We queried a database of all men undergoing initial evaluation for PD at a single clinic between March 2014 and June 2016. Patients were administered a questionnaire regarding sexual health concerns with domains including erectile dysfunction, ejaculatory dysfunction, libido, and penile curvature. In the penile curvature section, patients were specifically asked: "Does the curvature cause your partner any pain during penetrative intercourse? (Y/N)." Patients' partners were not directly evaluated for conditions associated with dyspareunia. Additionally, patients interested in treatment for PD underwent objective curve assessment after intracavernosal injection of erectogenic medications along with penile duplex Doppler ultrasound. Statistical analysis was performed to identify differences in clinicopathologic variables and patient-responses to questionnaire prompts between patients who did and did not report partner pain with intercourse. RESULTS: A total of 322 patients with information available on partner pain were included in the study. Patients who reported partner pain had significantly higher subjective erectile rigidity (mean 5.9/10 vs. 4.8/10, P=0.02) and patient-reported penile curvature (47.7° vs. 33.3°, P<0.001) compared to those who did not report pain. Ventral curvatures were more common in men with partner pain (21% vs. 9% of men without, P<0.05). Furthermore, patients complaining of partner pain were more likely to report that PD had a negative impact on relationships and were more interested in pursuing surgical corrections. CONCLUSIONS: Men with superior erectile function, higher degrees of penile curvature and ventral curvatures were more likely to report partner pain during penetrative intercourse. These specific disease characteristics reported in this series may assist clinicians in identifying men who are more motivated to select more invasive therapies.

12.
Int J Urol ; 25(2): 146-150, 2018 02.
Article in English | MEDLINE | ID: mdl-29178540

ABSTRACT

OBJECTIVE: Artificial urinary sphincter malfunctions can occur in any of the individual components. Preoperative identification of the malfunctioning component can be valuable for patient counseling and surgical planning. The optimal strategy for repair of failed artificial urinary sphincter components is debated given the relative rarity of the situation. The aim of the present study was to evaluate the relationship of time to failure with failed artificial urinary sphincter component and to compare our outcomes of specific component versus complete device replacement. METHODS: From 1983 to 2011, 1805 artificial urinary sphincter procedures were carried out at Mayo Clinic (Rochester, Minnesota, USA), of which 1072 patients underwent primary artificial urinary sphincter placement. Clinical variables, including time to failure, were evaluated for association with component failure. Bootstrap analysis was used to estimate the differences in time to reach a fixed percentage of component failure. RESULTS: A total of 115 patients experienced device failure at a median follow up of 4.2 years. Urethral cuff, abdominal reservoir, scrotal pump and tubing malfunction occurred in 53 (4.9%), 26 (2.4%), 11 (1%) and 25 (2.3%) patients, respectively. Increasing age at the time of primary surgery was protective of cuff malfunction (hazard ratio 0.97, P = 0.04). Time to 3% urethral cuff failure outpaced other component failures (P < 0.05). Secondary failure-free rates after whole device versus specific component revisions were comparable (P = 0.38). CONCLUSIONS: Clinical predictors for artificial urinary sphincter failure continue to be difficult to establish. Although single component versus entire device replacement have similar outcomes, if pursuing single component revision, we recommend cuff-first interrogation in devices in place for >3 years, as this represents the most likely component to fail.


Subject(s)
Equipment Failure , Postoperative Complications/diagnosis , Urinary Incontinence, Stress/surgery , Urinary Sphincter, Artificial/adverse effects , Urologic Surgical Procedures, Male/instrumentation , Aged , Follow-Up Studies , Humans , Male , Middle Aged , Postoperative Complications/etiology , Postoperative Complications/surgery , Prognosis , Prostatectomy/adverse effects , Reoperation , Retrospective Studies , Time Factors , Treatment Outcome , Urinary Bladder/surgery , Urinary Incontinence, Stress/etiology , Urologic Surgical Procedures, Male/adverse effects
13.
Cent European J Urol ; 70(3): 306-313, 2017.
Article in English | MEDLINE | ID: mdl-29104796

ABSTRACT

INTRODUCTION: We aimed to develop and validate a self-reported QUAlity of Life Assessment in Spina bifida for Teenagers (QUALAS-T). MATERIAL AND METHODS: We drafted a 46-question pilot instrument using a patient-centered comprehensive item generation/refinement process. A group of 13-17 years olds with spina bifida (SB) was recruited online via social media and in person at SB clinics (2013-2015). Healthy controls were recruited during routine pediatrician visits. Final questions were identified based on clinical relevance, factor analysis and domain psychometrics. Teenagers with SB completed the validated generic Kidscreen-27 instrument. RESULTS: Median age of 159 participants was 15.2 years (42.0% male, 77.4% Caucasian), similar to 58 controls (p ≥ 0.06). There were 102 online and 57 clinic participants (82.8% of eligible). Patients, parents and an expert panel established face and content validity of the 2-domain, 10-question QUALAS-T. Internal consistency and test-retest reliability were high for the Family and Independence and Bladder and Bowel domains (Cronbach's alpha: 0.76-0.78, ICC: 0.72-0.75). The Bladder and Bowel domain is the same for QUALAS-T , QUALAS-A for adults and QUALAS-C for children. Correlations between QUALAS-T domains were low (r = 0.34), indicating QUALAS-T can differentiate between distinct HRQOL components. Correlations between QUALAS-T and Kidscreen-27 were also low (r ≤0.41). QUALAS-T scores were lower in teenagers with SB than without (p <0.0001). CONCLUSIONS: QUALAS-T is a short, valid HRQOL tool for adolescents with SB, applicable in clinical and research settings. Since the Bladder & Bowel domains for all QUALAS versions are the same, Bladder and Bowel HRQOL can be measured on the same scale from age 8 through adulthood.

14.
Investig Clin Urol ; 58(4): 241-246, 2017 07.
Article in English | MEDLINE | ID: mdl-28681033

ABSTRACT

PURPOSE: To evaluate the impact of incontinence etiology on artificial urinary sphincter (AUS) device outcomes. MATERIALS AND METHODS: We identified 925 patients who underwent primary AUS placement from 1983 to 2011. The etiology of incontinence was categorized as radical prostatectomy alone, radical prostatectomy with radiation, benign prostate resection, and those with cryotherapy as a salvage prostate cancer treatment. Hazard regression and competing risk analyses were used to determine the association of the etiology of incontinence with device outcomes. RESULTS: The distribution of the 4 etiologies of incontinence included: 598 patients (64.6%) treated with prostatectomy alone, 206 (22.2%) with prostatectomy and pelvic radiation therapy, 104 (11.2%) with benign prostate resection, and 17 (1.8%) with prior cryotherapy. With a median follow-up of 4.9 years (interquartile range, 1.2-8.8 years), there was significant difference in the cumulative incidence of device infection/urethral erosion events between the four etiologies (p=0.003). On multivariable analysis, prior cryotherapy (reference prostatectomy alone; hazard ratio [HR], 3.44; p=0.01), older age (HR, 1.07; p=0.0009) and history of a transient ischemic attack (HR, 2.57; p=0.04) were associated with an increased risk of device infection or erosion. Notably, pelvic radiation therapy with prostatectomy was not associated with an increased risk of device infection or erosion (reference prostatectomy alone, p=0.30). CONCLUSIONS: Compared to prostatectomy alone, prior treatment with salvage cryotherapy for recurrent prostate cancer was associated with an increased risk of AUS infection/erosion, whereas radiation (in addition to prostatectomy) was not.


Subject(s)
Urinary Incontinence/etiology , Urinary Sphincter, Artificial , Aged , Cryotherapy/adverse effects , Humans , Kaplan-Meier Estimate , Male , Multivariate Analysis , Neoplasm Recurrence, Local/complications , Prostatectomy/adverse effects , Prostatic Neoplasms/complications , Prostatic Neoplasms/mortality , Prostatic Neoplasms/surgery , Prosthesis-Related Infections/etiology , Retrospective Studies , Risk Factors , Salvage Therapy/methods , Treatment Outcome , Urinary Incontinence/mortality
15.
J Urol ; 198(4): 795-802, 2017 10.
Article in English | MEDLINE | ID: mdl-28396181

ABSTRACT

PURPOSE: Chronic kidney disease may adversely affect survival following nephrectomy. Proteinuria is increasingly used as a marker of kidney disease. However, the relationship between preoperative proteinuria and survival after nephrectomy remains incompletely characterized. We evaluated the association of preoperative proteinuria with overall and cancer specific survival using our institutional nephrectomy registry. MATERIALS AND METHODS: We identified 1,846 patients with localized clear cell renal cell carcinoma treated with curative intent (radical or partial nephrectomy) between 1995 and 2010. Patients were categorized for analysis based on preoperative proteinuria severity (mild, moderate or severe). Overall and cancer specific survival was estimated by the Kaplan-Meier method. Cox proportional hazards regression models were used to assess for variables associated with overall and cancer specific mortality. RESULTS: Preoperative urine protein testing was available in 1,347 patients (73%). A total of 804 patients (60%) were classified with mild proteinuria (less than 150 mg per day), 332 (25%) were classified with moderate proteinuria (150 to 500 mg per day) and 211 (16%) were classified with severe proteinuria (greater than 500 mg per day). On multivariable analysis with mild proteinuria as the reference category the adjusted HR for all cause mortality was 1.18 (95% CI 0.95-1.48, p = 0.14) for moderate proteinuria and 1.61 (95% CI 1.26-2.07, p <0.001) for severe proteinuria. However, the proteinuria level was not associated with cancer specific survival. CONCLUSIONS: Severe preoperative proteinuria is associated with worse overall survival following radical or partial nephrectomy for localized clear cell renal cell carcinoma. Preoperative proteinuria should be evaluated in patients undergoing nephrectomy and considered when estimating overall patient health status.


Subject(s)
Carcinoma, Renal Cell/surgery , Kidney Neoplasms/surgery , Nephrectomy/adverse effects , Proteinuria/diagnosis , Renal Insufficiency, Chronic/diagnosis , Adult , Aged , Aged, 80 and over , Biomarkers/urine , Carcinoma, Renal Cell/mortality , Carcinoma, Renal Cell/urine , Female , Glomerular Filtration Rate , Humans , Kidney Neoplasms/mortality , Kidney Neoplasms/urine , Male , Middle Aged , Nephrectomy/methods , Practice Guidelines as Topic , Preoperative Care/methods , Preoperative Care/standards , Preoperative Period , Proteinuria/mortality , Proteinuria/urine , Registries/statistics & numerical data , Renal Insufficiency, Chronic/mortality , Renal Insufficiency, Chronic/urine , Retrospective Studies , Risk Factors , Severity of Illness Index , Young Adult
16.
World J Urol ; 35(6): 951-956, 2017 Jun.
Article in English | MEDLINE | ID: mdl-27722874

ABSTRACT

PURPOSE: To compare our experience with salvage laparoscopic pyeloplasty, using a matched control set of primary laparoscopic pyeloplasty patients. METHODS: We retrospectively reviewed patients who underwent laparoscopic pyeloplasty from 1996 to 2014 by a single surgeon. At least 12 months of follow-up was required. Salvage patients were matched 1:3 with primary patients. Matching was based on age ±5 years, body mass index (BMI) ±5, and type of pyeloplasty (dismembered vs. non-dismembered). Primary outcome was failure as defined as re-intervention following laparoscopic pyeloplasty (does not include temporary stenting without definitive retreatment). RESULTS: Of 128 laparoscopic pyeloplasty procedures, ten were salvage. These patients were matched to 26 patients who underwent a primary laparoscopic pyeloplasty in a 1:3 manner. One salvage pyeloplasty failed to match due to BMI, and the closest matches were made. Four salvage patients had one overlapping match, reducing the primary group to 26 patients. There were no differences in pre-, intra-, and postoperative variables between groups, except for operative time (salvage 247 min, primary 175 min, p = 0.03). With similar duration of radiologic and symptomatic follow-up, there was no significant difference in the rate of freedom from intervention. CONCLUSION: When matching for factors that could affect success, salvage laparoscopic pyeloplasty performed as well as primary pyeloplasty except for a longer operative time. In experienced hands, salvage laparoscopic pyeloplasty for ureteropelvic junction obstruction recurrence after prior pyeloplasty is a safe and effective procedure, and should be considered an excellent alternative to the more commonly recommended endopyelotomy.


Subject(s)
Kidney Pelvis/surgery , Laparoscopy/methods , Salvage Therapy/methods , Ureteral Obstruction/surgery , Urologic Surgical Procedures/methods , Adult , Case-Control Studies , Databases, Factual , Female , Follow-Up Studies , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Nephrotomy , Proportional Hazards Models , Recovery of Function/physiology , Retrospective Studies , Risk Assessment , Statistics, Nonparametric , Treatment Outcome , Ureteral Obstruction/diagnosis
17.
Urology ; 92: 57-62, 2016 Jun.
Article in English | MEDLINE | ID: mdl-26968489

ABSTRACT

OBJECTIVE: To evaluate the safety and efficacy of intraoperative tranexamic acid (TA), an antifibrinolytic, in reducing perioperative blood transfusion (PBT) for patients undergoing open radical cystectomy (RC) for bladder cancer. MATERIALS AND METHODS: We instituted a change in our institutional clinical practice starting in April 2013, whereby all patients undergoing open RC were administered intraoperative intravenous TA. Patients with a history of venous thromboembolism (VTE) or coronary stent insertion within the year prior to RC did not receive TA. Receipt of a PBT, defined as transfusion of red blood cells during RC or within the postoperative hospitalization, and VTE within 30 days of RC were recorded and compared with a matched cohort of patients treated with RC at our center prior to the initiation of TA utilization. RESULTS: A total of 103 patients received TA during open RC between April 2013 and July 2015. These patients were matched 1:2 to historic controls. We found that TA infusion was associated with a significantly decreased rate of PBT, as 32 of 103 (31.1%) patients treated with TA received a PBT, versus 115 of 200 (57.7%) matched controls (P < .0001). Importantly, TA did not significantly increase the rate of perioperative VTE, as 5 patients (4.9%) who received TA were diagnosed with a VTE within 30 days of RC, compared with 6 (3.0%) of the matched controls (P = .52). CONCLUSION: We noted that the use of intraoperative TA during open RC was associated with a significant reduction in PBT, and did not significantly increase perioperative VTE risk.


Subject(s)
Antifibrinolytic Agents/administration & dosage , Blood Transfusion/statistics & numerical data , Cystectomy/methods , Intraoperative Care , Tranexamic Acid/administration & dosage , Aged , Antifibrinolytic Agents/adverse effects , Female , Humans , Infusions, Intravenous , Male , Middle Aged , Retrospective Studies , Tranexamic Acid/adverse effects , Treatment Outcome
18.
Urology ; 87: 178-84, 2016 Jan.
Article in English | MEDLINE | ID: mdl-26456744

ABSTRACT

OBJECTIVE: To develop and validate a self-reported health-related QUAlity of Life Assessment in Spina bifida for Children (QUALAS-C). METHODS: We drafted a 27-question pilot instrument using a patient-centered comprehensive item generation and refinement process. It was administered to a sample of children 8-12 years old with spina bifida (SB) recruited online via social media and in person at an outpatient SB clinic (January 2013-September 2014). Healthy controls were recruited at routine pediatrician visits. Validation and final questions were determined based on clinical relevance, high loadings on factor analysis, and domain psychometrics. Children with SB also completed the validated generic Kidscreen-27 instrument. RESULTS: Median age of 150 participants was 9.6 years (60.7% male, 72.7% Caucasian), similar to 46 controls (P ≥ .10). There were 97 online and 53 clinic participants (89.0% and 84.2% of eligible, respectively). Face and content validities of the 2-domain, 10-question QUALAS-C were established by patients, parents, and experts. Internal consistency and test-retest reliability was high for the Esteem & Independence and Bladder & Bowel domains (Cronbach's alpha: 0.72-0.76, ICC: 0.74-0.77). Correlations between QUALAS-C domains were low (r = 0.51), indicating that QUALAS-C can differentiate between two distinct health-related quality of life components. Correlations between QUALAS-C and Kidscreen-27 were also low (r ≤ 0.44). QUALAS-C scores were significantly lower in children with SB than without (P < .0001). CONCLUSION: QUALAS-C is a short, valid health-related quality of life tool for children with SB. It will be useful in clinical and research settings.


Subject(s)
Quality of Life , Sickness Impact Profile , Spinal Dysraphism/psychology , Surveys and Questionnaires/standards , Child , Humans , Male , Pilot Projects , Reproducibility of Results , Spinal Dysraphism/diagnosis
19.
Urol Pract ; 3(6): 462-467, 2016 Nov.
Article in English | MEDLINE | ID: mdl-37592606

ABSTRACT

INTRODUCTION: We evaluated the safety and efficacy of extended duration of pharmacological prophylaxis for preventing symptomatic venous thromboembolism following radical cystectomy. METHODS: We recorded symptomatic venous thromboembolism and lymphocele events within 30 days of radical cystectomy among patients treated with extended duration of pharmacological prophylaxis (enoxaparin 40 mg subcutaneously daily for 30 days). We compared these outcomes to those in the cohort of patients who underwent radical cystectomy at our institution in the year prior to extended prophylaxis implementation. Unadjusted descriptive statistics and univariate analyses were performed using the Pearson test or the Fisher chi-square test for categorical variables and the Wilcoxon rank sum test for continuous variables. RESULTS: We analyzed the records of 52 patients who did and 82 who did not receive extended duration of pharmacological prophylaxis after radical cystectomy. Only 1 patient (1.9%) discharged home on extended prophylaxis was diagnosed with venous thromboembolism within 30 days of RC compared to 5 (6.1%) who had not received extended prophylaxis. In 3 patients symptomatic lymphocele developed within 30 days of radical cystectomy, including 1 (1.9%) who had received extended prophylaxis and 2 (2.4%) who had not. No patient in either cohort was rehospitalized for bleeding complications. CONCLUSIONS: Our initial experience suggests that extended duration of pharmacological prophylaxis is associated with a lower rate of venous thromboembolism following radical cystectomy and it does not increase the risk of bleeding or symptomatic lymphocele. These data warrant validation in larger patient cohorts, ideally in the prospective clinical trial setting.

20.
Urol Pract ; 2(6): 335-342, 2015 Nov.
Article in English | MEDLINE | ID: mdl-37559287

ABSTRACT

INTRODUCTION: Interest on the impact of variant histology in bladder cancer prognosis is increasing. Although squamous differentiation is the most well characterized, only recently have less common variants gained increased recognition. We assessed whether squamous differentiation conferred a worse prognosis than nonvariant urothelial bladder cancer in a contemporary cohort of patients treated with radical cystectomy given the increased awareness of other less common variants. METHODS: We identified patients with squamous differentiation or nonvariant histology on transurethral resection of bladder tumor and/or cystectomy pathology during a 10-year period. Disease specific and overall survival were evaluated using Kaplan-Meier methodology. Cox regression was used to assess variables associated with mortality. RESULTS: Between 2003 and 2013, 934 patients underwent cystectomy for urothelial bladder cancer. Overall 617 nonvariant and 118 squamous differentiation cases were identified, and the remainder was nonsquamous differentiation variant histology. Overall 75% of patients with squamous differentiation had muscle invasive disease at diagnosis compared with 59% of those with nonvariant histology (p=0.002). Nonorgan confined disease at cystectomy was more common in patients with squamous differentiation (57% vs 44%, p=0.009). Among cases on neoadjuvant chemotherapy 20% (9 of 45) of nonvariant and 13% (1 of 8) of squamous differentiation were pT0N0 (p=0.527). Median followup was 52 months. Adjusted for demographics, pathological stage and chemotherapy, squamous differentiation was not associated with an increased risk of disease specific (HR 1.35, 95% CI 0.90-2.04, p=0.150) or all cause mortality (HR 0.90, 95% CI 0.60-1.25, p=0.515). CONCLUSIONS: In a contemporary cohort of urothelial bladder cancer with recognition and characterization of less commonly described variants, squamous differentiation is not associated with a worse disease specific and all cause mortality when compared to a pure nonvariant cohort.

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